[
Effective March 1, 2016, AmeriHealth will adopt new claims reporting
requirements for drugs obtained from in-network home infusion providers. The
following information will be required when submitting drug claims for home
infusion vendors that are not owned by a hospital or health system in the
AmeriHealth provider network:
- NDC. The specific National Drug Code (NDC) that corresponds to the
drug formulation administered to the member must be reported.
- HCPCS or CPT® codes. The specific Healthcare Common
Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code
for the drug must be reported. Exception: For drugs without a specific
HCPCS or CPT code, report the J3490 or J3590 not otherwise classified (NOC)
code, as appropriate.
- Units of drug administered. Drug units must be reported in multiples
of the dosage unit specified in the HCPCS/CPT code narrative. Exception:
For drugs without a specific HCPCS or CPT code, report the units in multiples
of the drug units specified in the NDC.
Failure to include these components in a claim may result in delayed processing
and reimbursement.
Note: Precertification requests submitted through the
NaviNet® web portal will continue to follow the same submission
process that is in effect today.
For more information
The following claim payment policies are being updated to address these new
billing requirements and provide specific claims examples:
- Commercial: #00.01.49b: Reporting Requirements for Drugs and
Biologics
- Medicare Advantage: #MA00.024a: Reporting Requirements for Drugs and
Biologics
View the Notifications for these policies by visiting our
Medical Policy
Portal. Select
Accept and Go to Medical Policy Online, and then
select
Commercial or
Medicare Advantage under Active
Notifications.
We ask that you review these policies in their entirety and share them with
your staff so they can become familiar with the new requirements prior to March
1, 2016.
Please note that this change only applies to home infusion vendors that are
not owned by hospitals or health systems in the AmeriHealth provider
network. Home infusion vendors owned by hospitals or health systems in the
AmeriHealth provider network should continue to bill according to the terms of
their contract.
NaviNet is a registered trademark of
NaviNet, Inc.
]